What is the treatment for herpes simplex skin infections?

Treatment of Herpes Simplex Skin Infections

For herpes simplex skin infections, oral antiviral therapy with valacyclovir, acyclovir, or famciclovir is the recommended first-line treatment, with specific dosing regimens depending on the location and severity of infection. 1

First-Line Treatment Options

Oral Antiviral Medications

• Valacyclovir

  • Herpes labialis: 1000 mg three times daily for 7 days 1
  • Genital herpes (episodic): 1000 mg twice daily for 1 day 1
  • Genital herpes (suppressive): 500 mg daily 1

• Acyclovir

  • Herpes labialis/orolabial: 400 mg five times daily for 7 days 1
  • Genital herpes (episodic): 800 mg five times daily for 5 days 2
  • Genital herpes (suppressive): 400 mg twice daily 1

• Famciclovir

  • Herpes labialis: 1500 mg as a single dose 3
  • Genital herpes (episodic): 1000 mg twice daily for 1 day 3
  • Genital herpes (suppressive): 250 mg twice daily 3

Treatment Selection Considerations

• Valacyclovir and famciclovir offer improved bioavailability and more convenient dosing schedules compared to acyclovir 4
• Early treatment initiation (within first 48 hours of symptom onset) maximizes effectiveness 1
• For immunocompromised patients, higher doses and longer treatment durations are recommended 1

Special Populations

Immunocompromised Patients

• Higher oral doses are recommended: acyclovir 400 mg 3-5 times daily 1
• Treatment should continue until complete healing of lesions 1
• For severe systemic infections: intravenous acyclovir or foscarnet with discontinuation of immunosuppressants 1

Patients with Renal Impairment

• Dose adjustments are necessary based on creatinine clearance 1
• For acyclovir with CrCl <10 mL/min: 800 mg every 12 hours 1
• For valacyclovir with CrCl 10-29 mL/min: 500 mg every 24 hours 1

Children

• For children under 45 kg: acyclovir 20 mg/kg body weight (maximum 800 mg/dose) orally 4 times daily for 7-10 days 1

Resistant Herpes Simplex Infections

• Resistance to standard antivirals remains low (<0.5% in immunocompetent hosts) 5
• Higher resistance rates in immunocompromised patients: acyclovir 7% vs <0.5% and penciclovir 2.1% vs 0.22% 5
• For resistant cases, consider foscarnet (40 mg/kg three times daily or 60 mg/kg twice daily) 6
• Topical trifluridine (TFT) can be used for accessible mucocutaneous lesions 6

Supportive Care

• Topical anesthetics, warm sitz baths, and oral analgesics can provide symptomatic relief 1
• For oral lesions: viscous lidocaine 2% mouthwash, topical NSAIDs, and sodium bicarbonate mouthwash 1
• Keep lesions clean and dry 1

Patient Education

• Apply medication at the first sign of prodrome (tingling, burning, or itching) 1
• Wash hands before and after application 1
• Continue treatment for the full prescribed duration even if symptoms improve 1
• Abstain from sexual contact during outbreaks or prodromal symptoms 1
• Use condoms consistently to reduce transmission risk 1

Common Pitfalls to Avoid

• Delayed treatment initiation: Antivirals are most effective when started within 48 hours of symptom onset
• Inadequate dosing: Ensure proper dosing based on infection site and patient factors
• Failure to adjust for renal impairment: Antiviral medications require dose adjustments in patients with decreased renal function
• Overlooking resistance: Consider resistance in immunocompromised patients with poor response to standard therapy
• Neglecting supportive care: Pain management and keeping lesions clean are important adjuncts to antiviral therapy